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Interventions that encourage return to normal function and reduce fear of physical activity have been shown to improve outcomes for patients with back pain, but routine medical care for back pain often does not provide such interventions. This paper proposes a stepped-care approach that addresses the functional outcomes of back pain. Step 1, which is relevant to most patients, addresses the common fears of patients with back pain and encourages patients to resume normal activities. Step 2, which targets the substantial minority of patients who require more than simple advice to resume activities, provides brief, structured interventions that support physical exercise and return to normal activities. Step 3 targets patients who require more intensive interventions, including treatment of psychological illness when present, before they can return to normal activities in work and family life. Patient needs relevant to these three levels of care are delineated. This stepped-care approach provides a framework for sequencing progressively more intensive interventions and coordinating the efforts of primary care physicians, allied health professionals, behavioral health clinicians, and patients to improve functional outcomes in patients with back pain. [ABSTRACT FROM AUTHOR]

Objective: To compare the effectiveness of a multifaceted intervention in patients with depression in primary care with the effectiveness of "usual care" by the primary care physician.Design: A randomized controlled trial among primary care patients with major depression or minor depression.Patients: Over a 12-month period a total of 217 primary care patients who were recognized as depressed by their primary care physicians and were willing to take antidepressant medication were randomized, with 91 patients meeting criteria for major depression and 126 for minor depression.Interventions: Intervention patients received increased intensity and frequency of visits over the first 4 to 6 weeks of treatment (visits 1 and 3 with a primary care physician, visits 2 and 4 with a psychiatrist) and continued surveillance of adherence to medication regimens during the continuation and maintenance phases of treatment. Patient education in these visits was supplemented by videotaped and written materials.Main Outcome Measures: Primary outcome measures included short-term (30-day) and long-term (90-day) use of antidepressant medication at guideline dosage levels, satisfaction with overall care for depression and antidepressant medication, and reduction in depressive symptoms.Results: In patients with major depression, the intervention group had greater adherence than the usual care controls to adequate dosage of antidepressant medication for 90 days or more (75.5% vs 50.0%; P < .01), were more likely to rate the quality of the care they received for depression as good to excellent (93.0% vs 75.0%; P < .03), and were more likely to rate antidepressant medications as helping somewhat to helping a great deal (88.1% vs 63.3%; P < .01). Seventy-four percent of intervention patients with major depression showed 50% or more improvement on the Symptom Checklist-90 Depressive Symptom Scale compared with 43.8% of controls (P < .01), and the intervention patients also demonstrated a significantly greater decrease in depression severity over time compared with controls (P < .004). In patients with minor depression, the intervention group had significantly greater adherence than controls to adequate dosage of antidepressant medication for 90 days or more (79.7% vs 40.3%; P < .001) and more often rated antidepressant medication as helping somewhat to helping a great deal (81.8% vs 61.4%; P < .02). However, no significant differences were found between the intervention and control groups in the percentage of patients who were satisfied with the care they received for depression (94.4% vs 89.3%), in the percentage who experienced a 50% or more decrease in depressive symptoms, or in the decrease of depressive symptoms over time.Conclusion: A multifaceted intervention consisting of collaborative management by the primary care physician and a consulting psychiatrist, intensive patient education, and surveillance of continued refills of antidepressant medication improved adherence to antidepressant regimens in patients with major and with minor depression. It improved satisfaction with care and resulted in more favorable depressive outcomes in patients with major, but not minor, depression. [ABSTRACT FROM AUTHOR]

Objective: To prospectively examine the association of depression with risks for advanced macrovascular and microvascular complications among patients with type 2 diabetes.Research Design and Methods: A longitudinal cohort of 4,623 primary care patients with type 2 diabetes was enrolled in 2000-2002 and followed through 2005-2007. Advanced microvascular complications included blindness, end-stage renal disease, amputations, and renal failure deaths. Advanced macrovascular complications included myocardial infarction, stroke, cardiovascular procedures, and deaths. Medical record review, ICD-9 diagnostic and procedural codes, and death certificate data were used to ascertain outcomes in the 5-year follow-up. Proportional hazard models analyzed the association between baseline depression and risks of adverse outcomes.Results: After adjustment for prior complications and demographic, clinical, and diabetes self-care variables, major depression was associated with significantly higher risks of adverse microvascular outcomes (hazard ratio 1.36 [95% CI 1.05-1.75]) and adverse macrovascular outcomes (1.24 [1.0-1.54]).Conclusions: Among people with type 2 diabetes, major depression is associated with an increased risk of clinically significant microvascular and macrovascular complications over the ensuing 5 years, even after adjusting for diabetes severity and self-care activities. Clinical and public health significance of these findings rises as the incidence of type 2 diabetes soars. Further research is needed to clarify the underlying mechanisms for this association and to test interventions to reduce the risk of diabetes complications among patients with comorbid depression. [ABSTRACT FROM AUTHOR]

Background: Long-term opioid therapy for chronic noncancer pain is becoming increasingly common in community practice. Concomitant with this change in practice, rates of fatal opioid overdose have increased. The extent to which overdose risks are elevated among patients receiving medically prescribed long-term opioid therapy is unknown.Objective: To estimate rates of opioid overdose and their association with an average prescribed daily opioid dose among patients receiving medically prescribed, long-term opioid therapy.Design: Cox proportional hazards models were used to estimate overdose risk as a function of average daily opioid dose (morphine equivalents) received at the time of overdose.Setting: HMO.Patients: 9940 persons who received 3 or more opioid prescriptions within 90 days for chronic noncancer pain between 1997 and 2005.Measurements: Average daily opioid dose over the previous 90 days from automated pharmacy data. Primary outcomes--nonfatal and fatal overdoses--were identified through diagnostic codes from inpatient and outpatient care and death certificates and were confirmed by medical record review.Results: 51 opioid-related overdoses were identified, including 6 deaths. Compared with patients receiving 1 to 20 mg/d of opioids (0.2% annual overdose rate), patients receiving 50 to 99 mg/d had a 3.7-fold increase in overdose risk (95% CI, 1.5 to 9.5) and a 0.7% annual overdose rate. Patients receiving 100 mg/d or more had an 8.9-fold increase in overdose risk (CI, 4.0 to 19.7) and a 1.8% annual overdose rate.Limitations: Increased overdose risk among patients receiving higher dose regimens may be due to confounding by patient differences and by use of opioids in ways not intended by prescribing physicians. The small number of overdoses in the study cohort is also a limitation.Conclusion: Patients receiving higher doses of prescribed opioids are at increased risk for overdose, which underscores the need for close supervision of these patients.Primary Funding Source: National Institute of Drug Abuse. [ABSTRACT FROM AUTHOR]

Background: Case management by health care assistants in small primary care practices provides unclear benefit for improving depression symptoms.Objective: To determine whether case management provided by health care assistants in small primary care practices is more effective than usual care in improving depression symptoms and process of care for patients with major depression.Design: Cluster randomized, controlled trial. A central automated system generated the randomization scheme, which was stratified by urban and rural practices; allocation sequence was concealed until groups were assigned.Setting: 74 small primary care practices in Germany from April 2005 to September 2007.Patients: 626 patients age 18 to 80 years with major depression.Intervention: Structured telephone interview to monitor depression symptoms and support for adherence to medication, with feedback to the family physician.Measurements: Depression symptoms at 12 months, as measured by the Patient Health Questionnaire-9 (PHQ-9); secondary outcomes were patient assessment of chronic illness care, adherence to medication, and quality of life.Results: A total of 310 patients were randomly assigned to case management and 316 to usual care. At 12 months, 249 intervention recipients and 278 control patients were assessed; 555 patients were included in a modified intention-to-treat-analysis (267 intervention recipients vs. 288 control patients). Compared with control patients, intervention recipients had lower mean PHQ-9 values in depression symptoms (-1.41 [95% CI, -2.49 to -0.33]; P = 0.014), more favorable assessments of care (3.41 vs. 3.11; P = 0.011), and increased treatment adherence (2.70 vs. 2.53; P = 0.042). Quality-of-life scores did not differ between groups.Limitation: Patients, health care assistants, family physicians, and researchers were not blinded to group assignment, and 12-month follow-up of patients was incomplete.Conclusion: Case management provided by primary care practice-based health care assistants may reduce depression symptoms and improve process of care for patients with major depression more than usual care.Primary Funding Source: German Ministry of Education and Research. [ABSTRACT FROM AUTHOR]

BackgroundThe relationship between mental and physical disorders is well established, but there is less consensus as to the nature of their joint association with disability, in part because additive and interactive models of co-morbidity have not always been clearly differentiated in prior research.MethodEighteen general population surveys were carried out among adults as part of the World Mental Health (WMH) Survey Initiative (n=42 697). DSM-IV disorders were assessed using face-to-face interviews with the Composite International Diagnostic Interview (CIDI 3.0). Chronic physical conditions (arthritis, heart disease, respiratory disease, chronic back/neck pain, chronic headache, and diabetes) were ascertained using a standard checklist. Severe disability was defined as on or above the 90th percentile of the WMH version of the World Health Organization Disability Assessment Schedule (WHODAS-II).ResultsThe odds of severe disability among those with both mental disorder and each of the physical conditions (with the exception of heart disease) were significantly greater than the sum of the odds of the single conditions. The evidence for synergy was model dependent: it was observed in the additive interaction models but not in models assessing multiplicative interactions. Mental disorders were more likely to be associated with severe disability than were the chronic physical conditions.ConclusionsThis first cross-national study of the joint effect of mental and physical conditions on the probability of severe disability finds that co-morbidity exerts modest synergistic effects. Clinicians need to accord both mental and physical conditions equal priority, in order for co-morbidity to be adequately managed and disability reduced. [ABSTRACT FROM AUTHOR]

The objective of the present study was to identify favourable exotic Quantitative Trait Locus (QTL) alleles for the improvement of agronomic traits in the BC2DH population S42 derived from a cross between the spring barley cultivar Scarlett and the wild barley accession ISR42-8 ( Hordeum vulgare ssp. spontaneum). QTLs were detected as a marker main effect and/or a marker × environment interaction effect ( M × E) in a three-factorial ANOVA. Using field data of up to eight environments and genotype data of 98 SSR loci, we detected 86 QTLs for nine agronomic traits. At 60 QTLs the marker main effect, at five QTLs the M × E interaction effect, and at 21 QTLs both the effects were significant. The majority of the M × E interaction effects were due to changes in magnitude and are, therefore, still valuable for marker assisted selection across environments. The exotic alleles improved performance in 31 (36.0%) of 86 QTLs detected for agronomic traits. The exotic alleles had favourable effects on all analysed quantitative traits. These favourable exotic alleles were detected, in particular on the short arm of chromosome 2H and the long arm of chromosome 4H. The exotic allele on 4HL, for example, improved yield by 7.1%. Furthermore, the presence of the exotic allele on 2HS increased the yield component traits ears per m2 and thousand grain weight by 16.4% and 3.2%, respectively. The present study, hence, demonstrated that wild barley does harbour valuable alleles, which can enrich the genetic basis of cultivated barley and improve quantitative agronomic traits. [ABSTRACT FROM AUTHOR]

PURPOSE: We sought to determine whether relationship style in patients with diabetes receiving depression treatment is associated with differential quality of care and depression outcomes. METHODS: From 9 health maintenance organization clinics, 324 primary care patients with diabetes and comorbid major depression and/or dysthymia participated in the Pathways randomized controlled trial of collaborative care for depression (n = 160) versus usual care (n = 164). The intervention provided outreach, enhanced support of antidepressant medication use, and problem-solving treatment delivered by nurse case managers. Using attachment theory principles, we categorized patients as having an independent (n = 190) or interactive (n = 134) relationship style. We assessed whether patient relationship style moderated treatment group differences in quality of care and depression outcomes. RESULTS: Among independent relationship style patients, the intervention resulted in significantly greater satisfaction with depression care in the first 6 months and 47 more depression-free days (P < 0.0003) based on the Hopkins Symptom Checklist at 12 months, compared with usual care. There were no significant treatment group differences in satisfaction with care or depression outcomes among patients with interactive relationship style. Among patients receiving the intervention, those with an independent relationship style received significantly more problem-solving treatment sessions as compared with patients with an interactive relationship style. CONCLUSION: Among depressed patients with diabetes, the Pathways collaborative care intervention improved quality of care for depression compared with usual care in both relationship style groups but was associated with significantly better depressive outcomes and greater satisfaction with care compared with usual care in patients with independent but not interactive relationship style. [ABSTRACT FROM AUTHOR]

Background. In patients with chronic medical conditions, depression can be viewed as an expected reaction to illness or an independent condition requiring active treatment. We examine how clinical and functional outcomes of depression treatment compare in primary-care patients with and without chronic medical illness.Method. Health plan administrative data were used to identify primary-care patients initiating antidepressant treatment, including a general sample (n=204) and cohorts with ischemic heart disease (n=68), diabetes (n=93), or obstructive lung disease (n=74). Telephone interviews at baseline, 2 months, and 6 months assessed depression (Structured Clinical Interview for DSM-IV, Hopkins Symptom Checklist depression scale), functional status (SF-36) and days of disability because of to illness.Results. At baseline, depression severity in patients with diabetes and obstructive lung disease was similar to those without medical co-morbidity, but significantly lower in those with ischemic heart disease. Social and emotional functioning were similar across all groups, but those with chronic medical illness reported greater physical impairment. All groups showed significant improvement in depression over six months, but the rate of improvement was significantly slower in those with heart disease. All groups showed significant and similar improvement in social and emotional functioning, but physical functioning showed little change. Days of disability and restricted activity improved significantly in all groups. Improvement in depression during treatment was strongly related to change in disability.Conclusions. Patients with chronic medical illness and co-morbid depression show significant improvements in mood, social and emotional functioning, and disability following initiation of depression treatment. Depression may be a stronger determinant of disability than is stable chronic medical illness. [ABSTRACT FROM AUTHOR]

Objectives: Major depression occurs in approximately 11% to 15% of patients with diabetes and is associated with poor glycemic control and adverse medical outcomes. This study examined the rates and predictors of recognition of depression among primary care patients with diabetes and comorbid major depression and the quality of depression care provided during a 12-month period.Methods: This study used automated utilization, pharmacy, and laboratory data from a health maintenance organization to describe the rate of recognition of depression and quality of care provided for patients with major depression and diabetes in the 12-month period before diagnosis. Major depression was diagnosed based on the Patient Health Questionnaire (PHQ-9) that was included in a mail survey sent to 9063 patients on the Group Health diabetes registry from 9 primary care clinics.Results: Approximately 51% of patients with major depression and diabetes were recognized as depressed by the health care system. Women were more likely to be recognized (odds ratio [OR] 1.58, 95% confidence interval [CI 1.26-1.97]), as were those with dysthymia (OR 3.44, 95% CI 2.08-5.72), panic attacks (OR 1.55, 95% CI 1.19-2.19), patients with more than 7 primary care visits (OR 1.42, 95% CI 1.06-1.91) and patients reporting poor health (OR 1.62, 95% CI 1.04-2.53). Of the 51% of patients with major depression who were recognized, 43% received 1 or more antidepressant prescriptions but only 6.7% received 4 or more psychotherapy sessions during a 12-month period.Discussion: There were large gaps in both recognition and quality of depression care provided to patients with major depression and diabetes within a health maintenance organization system. [ABSTRACT FROM AUTHOR]

In the present paper, we report on the selection of two sets of candidate introgression lines (pre-ILs) in spring barley. Two BC2DH populations, S42 and T42, were generated by introgressing an accession ofHordeum vulgaressp.spontaneum(ISR42-8, from Israel) into two different spring barley cultivars, Scarlett (S) and Thuringia (T). From these BC2DH populations two sets with 49 (S42) and 43 (T42) pre-ILs were selected, and their genomic architecture as revealed by SSR marker analysis was characterised. The selected pre-ILs cover at least 98.1% (S42) and 93.0% (T42) of the exotic genome in overlapping introgressions and contain on average 2 (S42) and 1.5 (T42) additional non-target introgressions. In order to illustrate a potential application and validation of these pre-ILs, the phenotypic effect of the exotic introgression at the locus of the major photoperiod response genePpd-H1was analysed. Pre-ILs carrying the introgression at thePpd-H1locus flowered significantly earlier than the elite parents, and the introgression maintained its effect across the two genetic backgrounds and across four tested environments. The selected pre-ILs represent a first promising step towards the assessment and utilization of genetic variation present in exotic barley. They may promote the breeding progress, serve for the verification of QTL effects and provide a valuable resource for the unravelling of gene function, e.g. by expression profiling or map-based cloning. [ABSTRACT FROM AUTHOR]

OBJECTIVE: This article uses data from two studies that have demonstrated the overall effectiveness of Collaborative Care interventions to evaluate factors associated with poor outcomes overall (general prognostic factors) and factors associated with greater or lesser effects of treatment (differential treatment effects). METHODS: Adult primary care patients initiating antidepressant treatment for major depression were randomized to usual care or to Collaborative Care, a structured depression treatment program that included planned, proactive and coordinated care with a health care team and informed, activated patients (n = 156, mean age = 43, 85% white). Response to treatment was defined as a 50% or greater reduction in depression at four months. RESULTS: High neuroticism and a history of recurrent major depression (3+ episodes) or dysthymia predicted poor outcomes in general. While the magnitude of the intervention effects differed, frequently cited predictors of persistence of depression (age, gender, depression severity, medical and psychiatric comorbidity) were not significantly associated with greater or lesser benefit from Collaborative Care (no differential treatment effects). Results demonstrate the robustness of intervention effects across numerous groups at risk for persistence of depression. CONCLUSIONS: These findings suggest that at the time of diagnosis it is not possible to predict who is most likely to benefit from Collaborative Care. Instead, outcomes of treatment should be routinely monitored among depressed patients to ensure optimal response. [ABSTRACT FROM AUTHOR]